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Approaches to the Measurement of Childhood Mortality a Comparative Review

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A comprehensive assay on kid mortality and its determinants in Bangladesh using frailty models

Athenaeum of Public Wellness volume 75, Article number:58 (2017) Cite this commodity

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Abstract

Background

Bangladesh has experienced a significant reduction of child bloodshed over the by decades which helped achieve the Millennium Development Goal 4 (MDG 4) target. But the mortality among nether-5 aged children is however relatively high and it needs a substantial effort to achieve the Sustainable Development Goal (SDG) target and decelerate the electric current charge per unit of under-five mortality. At this phase, it is hence important to explore the trend and determinants of under-5 bloodshed in lodge to reduce the vulnerability of kid's survival. The aim of this report is to explore the trends and identify the factors associated with mortality in children aged less than 5 years in Bangladesh.

Methods

Information from three repeatedly cross-exclusive Bangladesh Demographic and Wellness Surveys (BDHSs) for the year 2007, 2011 and 2014 were used. A stratified 2-stage sampling method was used to collect information on child and maternal health in these surveys. Cox's proportional hazards models with community and female parent level random furnishings (or frailty models) were fitted to place the associated factors with nether-5 mortality.

Results

Our study reveals that urban-rural disparity in child mortality has decreased over the time. The frailty models revealed that the combined result of birth order and preceding birth interval length, sexual activity of the child, maternal age at birth, female parent'southward working condition, parental education were the of import determinants associated with risk of child mortality. The risk of mortality too varied across divisions with Sylhet division beingness the most vulnerable one. Moreover, meaning and sizable frailty furnishings were found which indicates that the estimations of the unmeasured and unobserved mother and customs level factors on the risk of death were substantively important.

Conclusion

Our report suggests that community-based educational programs and public health interventions focused on birth spacing may turn out to be the near effective. Moreover, unobserved customs and familial effects need to be considered along with significant programmable determinants while planning for the child survival program.

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Groundwork

Child mortality is a vital indicator of child wellness and overall national development [1]. According to World Health Organization (WHO) [two], a substantial global progress has been made in reducing child deaths, from 12.seven 1000000 in 1990 to v.9 million in 2015. Since 1990, the global under-five bloodshed rate has dropped 53%, from 91 deaths per chiliad live births in 1990 to 43 in 2015. The world as a whole has been accelerating progress in reducing the under-five mortality rate. Between 1990 and 2015, 62 of the 195 countries with available estimates met the Millennium Development Goal four (MDG four) target of a ii-thirds reduction in the nether-5 bloodshed rate. Among them, 24 are low- and lower-heart income countries. Currently, 79 countries accept an under-five mortality rate college than 25 deaths per 1000 alive births [2].

Among these countries, Bangladesh has besides registered a substantive acceleration. Bangladesh has experienced a remarkable change in child bloodshed rates over the few decades, from 133 deaths to 46 deaths per chiliad live births with a rate of 65% pass up in the menstruum 1989-2014 [3]. Over these decades, extensive changes have occurred in health policy related to maternal wellness and newborn care, which could exist the underlying reason of reduced child bloodshed [iv]. Moreover, a notable increase in the coverage of interventions relevant to kid survival, such as births in a health facility, skilled nativity omnipresence, antenatal intendance visit, coverage of breastfeeding within one h of nascence and exclusive breastfeeding for children etc. had a significant contribution to reducing child mortality [4]. But the reduction in infant and newborn mortality has happened more slowly with a charge per unit of 56 and 46% in the period 1989-fourteen, respectively [five]. Although child mortality rate is decreasing over time, Bangladesh has to farther reduce kid mortality to obtain the Sustainable Evolution Goals (SDGs) [3]. Moreover, about 20% further reduction in baby mortality is needed to reach the Wellness, Population, and Diet Sector Development Programme (HPNSDP) target of 31 deaths per 1000 alive births in 2016 [6]. So, the study on child mortality is an important public wellness issue for Bangladesh. With the growing emphasis on the implementation of family planning programs in recent time, finding out the determinants of child mortality and its trends is also getting of import [vii].

The loftier fertility rate is boosted up by high baby and child bloodshed, because of the fear of expiry of the children at an early on age. There are many factors which are closely related to the mortality experience among children such as maternal education, household income condition etc [eight–ten]. Generally, non-educated mothers have more kid deaths than others [11]. Some demographic variables are associated with baby and kid mortality such as maternal age at marriage and during child's birth, nativity spacing blueprint, parity, maternal height and weight, and size of the children at birth [8–ten, 12]. Children of very young mothers (less than twenty years or 20-24 years) are at greater hazard of expiry and rate of mortality is higher for older women (greater than 35 years, especially higher for women older than 40 years) [thirteen, 14]. Many studies evidence that infant and child mortality is loftier among the kickoff born, but relatively depression among second and the third order births [fifteen]. The length of the birth interval has a negative association with the babe and child mortality, i.east., the smaller the birth interval, the higher is the child mortality [12]. Many other factors such as immunization condition of children and delivery practice may also influence babe and child mortality [16–18].

Some studies have been done by considering the necessity of analyzing the infant-child mortality and its determinants in Bangladesh [10, 19]. Kabir et al. [10] and the most recent study by Abir et al. [nineteen] were attempted to identify important factors influencing infant and kid mortality. The analyses of under-5 kid bloodshed data in previous studies were conducted by means of simple Cox's proportional hazards model considering time-to-consequence (decease) information independent [10, xix].

An assessment of determinants of child survival is necessary to reduce child mortality rates [xx]. This written report examines, in item, the socioeconomic and demographic factors associated with bloodshed among children in People's republic of bangladesh, and the extent to which the survival outcomes of children and siblings are associated. Afterward accounting for different known determinants of child mortality this type of association of kid survival outcomes has been attributed due to unobserved heterogeneity [21–23]. Moreover, this association of child survival outcomes arises in the context of clustered data. In developing countries, different studies of under-5 mortality accept largely utilized information from Demographic and Health Surveys (DHS). This national representative survey suggests that the lifetimes of children from the same cluster are correlated, and so are their risks of expiry, due to the sampling blueprint. This kind of dependency is frequently found at family (mother) level or community level. From the methodological point of view, statistical models that ignore this type of clustering can brand the study results biased because they violate the assumption of independence of event times. In this respect, proportional hazards models with random outcome or frailty models are of import because they allow for the correlation in survival experiences of children likewise as siblings and expected to give authentic estimates of determinants of mortality. Frailty models are also important in estimating the consequence of unmeasured and unobserved factors on the likelihood of decease. In this study, we command for correlation between issue times at the mother level and customs level, which as well helps to capture the effect of unobserved factors on the risk of child death.

Although there have been quite a few studies in the past identifying the socioeconomic determinants of child mortality in Bangladesh, due to the continuous interventions by the regime and non-regime organizations throughout the past few decades, nosotros believe many of the wellness-related and societal aspects have changed and it is worthwhile checking dorsum if the determinants have changed over the years or non. The objective of the nowadays written report is to assess the trends, socioeconomic and demographic determinants causing the decease of children nether five twelvemonth of historic period in Bangladesh, which would help the policy makers take necessary measures to hasten the mortality turn down.

Methods

Sampling blueprint and variables

Our study is based on the well-nigh contempo nationally representative Bangladesh Demographic and Health Surveys (BDHS): 2007, 2011 and 2014 [24]. Information from these surveys were collected at the individual level (always-married women at reproductive ages), and at the community level. These repeatedly cross exclusive surveys were designed to collect detailed information on a wide range of indicators such as fertility, wedlock, family planning, bloodshed, breastfeeding practices, nutritional status, maternal and child health, sensation and behavior regarding HIV/AIDS etc. In BDHSs, a two-stage stratified sampling was used where 600 clusters (enumeration areas, EAs) were selected with on an average 30 households per cluster. All surveys were conducted in collaboration with National Constitute of Population Research and Grooming (NIPORT), ICF International, U.s.a., and Mitra & Assembly. These three nationally representative surveys gathered information from a total of 10996, 17749, and 17863 households in the year 2007, 2011, and 2014, respectively.

In this study, we considered those children who were born within preceding v years from the survey years. Among the children, those who died before reaching their 5th birthday were treated as failure cases and children who were yet alive and did not attain their 5th birthday were treated as censored cases during the analysis. Nosotros excluded non-original resident and twin data from this dataset. Covariates in our analysis consists of the maternal age at marriage (" <18 years", " ≥eighteen years"), child'south sex ("male", "female person"), birth club ("1", "2-4", " ≥5"), preceding birth interval ("beginning", "short (<24 months)", "medium (25–48 months)", "large (≥49 months)"), maternal historic period at nativity (" <25 years", "25–34 years", " ≥35 years"), parental educational level ("no education", "principal", "secondary or higher"), religion ("Muslim", "others"), wealth alphabetize ("poor", "center", "rich"), exposure to media ("yes", "no"), maternal malnutrition ("underweight", "normal", "overweight or obese"), maternal working status ("yeah", "no"), paternal historic period (" ≤25 years", "26–35 years", " >35 years"), place of residence ("urban", "rural"), division ("Barisal", "Chittagong", "Dhaka", "Khulna", "Rajshahi", "Sylhet") and survey twelvemonth ("2007", '2011", "2014"). We accept merged Rangpur and Rajshahi divisions as Rajshahi division for BDHS 2011 and 2014 to match with BDHS 2007. Exposure to media of mothers was categorized as: 'yes' if the respondent was either watching TV or listening radio or reading newspaper at least one time a week, and 'no' if otherwise. Body mass index (BMI) was the primal indicator of maternal nutritional status. We categorized BMI (kg/m2) as "underweight (BMI <18.5)", "normal (eighteen.5-24.99)", "overweight or obese (≥ 25)". To study the trends and determinants of kid mortality in Bangladesh, nosotros pooled the iii cross-sectional survey data.

Models

The duration of survival since birth in months was used in measuring the adventure of death in childhood which was a time-to-event data. There were several possible model options. An event history assay procedure which was proposed by Cox is commonly used to examine the impact of various factors on the risk of death [25]. The main reward of this model is that it accounts for the trouble of censoring in data. Standard Cox's proportional hazards model is applicable when fourth dimension-to-upshot data are independent, but in this study, data are obtained from a cluster survey and assumed to be correlated. Information technology is assumed that the correlations are due to unobserved cluster (community or female parent) specific covariates. Ane approach is to adjust unobserved covariates known as frailty (random result) in the standard Cox's proportional hazards model which is popularly called a frailty model. The frailty model assumes that the hazard of death of an private is a function of measured factors and a random term on the baseline run a risk due to the unobserved cluster upshot. The model is of the form,

$$ h_{ij}\left(t\mid X_{ij}, u_{i}\correct)=u_{i} h_{0}(t) e^{\beta'X_{ij}}, $$

(i)

for time-to-event data, where i (ane,…,n) denotes the cluster, while j (i,…,north i ) denotes the observation (kid) within the cluster. The frailty, u i is a random positive quantity shared within the groups. Hither, h ij (t ∣ X ij ,u i ) is the hazard of child death at time t; h 0(t) is the baseline hazard, X ij is a vector of covariates with associated vector of fixed parameters β. The parameters of this model are estimated by maximizing the partial likelihood with respect to the parameters β. Different distributions can be considered for this frailty such as Gamma, lognormal, Gompertz etc. We causeless Gamma distributions for both the frailties corresponding to community and female parent in this report. Frailty distribution is considered based on mathematical convenience. If an approximate of variance parameter significantly differs from zero this volition point that unmeasured and unobserved factors shared by children of the same family unit or cluster have an impact on the risk of death, that means their survival risks are correlated. On the other mitt, child bloodshed does not differ between communities or mothers if the variance estimate is zero. In frailty models, the likelihood of death depends on the measured factors and the unmeasured community or mothers consequence and resulting hazard ratios are therefore mother or community specific which measure the event of a particular variable on the take chances of death within a particular mother or customs. To explore the dependence in frailty models, Kendall's τ is used which denotes the correlation of subjects' outcomes within groups or clusters [26]. A airtight-class expression exists for Kendall's τ under the Gamma frailty model. In addition, to quantify the magnitude of the effect of clustering within clusters median hazard ratio (MHR) is used, which is the median relative change in the take chances of the occurrence of the outcome when comparison identical subjects from two randomly selected dissimilar clusters that are ordered past risk [27].

The hazard ratios (HR) and their 95% confidence intervals (CI) obtained from the Cox's proportional hazards models with and without random effect were used to measure the associations of predictor variables with the under-5 deaths, which are the report outcomes in our case.

Results

Descriptive statistics

Table ane presents the distribution of child survival status by mother's historic period at nascence and birth order over the years. Results prove that about 7% of the starting time children died before reaching the fifth birthday among the mother with age at birth less than 25, which gradually decreased over the years (about 4.v% in 2014). For children with birth order 4–5, the pct of child decease reached from virtually 5% (in 2007) to about four% (in 2014). For children with birth club higher than 5, the decease toll was significantly loftier in 2007 which has decreased to a great extent subsequently. We will be cautious to draw any conclusion from this slice of data though because the number of children with higher than 5 birth order was understandably low for mothers aged below 25. Amid the mothers who anile 25–34 years during the nativity of their children, the percentage of child death didn't subtract much over the years for the first children. However, for birth guild four–5, the percentage of child death was about 3.5% in 2007 and 3% in 2014. The percentage of decease also decreased slowly for birth order more than than 5 and mothers aged above 35 years at birth, although this trend of failing over time is only slight while comparing with the same nativity orders for the <25 and 25–34 years anile (at birth) mothers.

Tabular array 1 Child survival and mortality by maternal age at birth and birth social club (survey year wise stratified)

Full size table

At that place are notable disparities in kid mortality across the household wealth status groups. The percentage of expressionless children from poor households were consistently more than the children from rich households. The graph shows that the percentage of mortality was declining among all groups, merely the rate was slow in the flow between 2011 to 2014 compared to the period betwixt 2007 to 2011 (Fig. ane). The urban and rural differences in the prevalence of child mortality are highly notable in 2007, but over the time this difference has reduced. The rate of failing mortality was not much notable in urban areas over the fourth dimension compared to the rural areas (Fig. two).

Fig. 1
figure 1

Trend of child mortality among the different groups of wealth alphabetize

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Fig. two
figure 2

Trend of child mortality across the rural and urban areas of residence

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Risk factors of child deaths

Tabular array 2 represents the potential risk factors associated with under-five child bloodshed in Bangladesh. Cox's proportional hazards model and frailty model were fitted to place the socio-economical and demographic correlates of kid mortality. The same gear up of covariates were used in all models. The selected socio-economic and demographic variables considered hither in the model are female parent'due south age at marriage and at childbirth, sex of the children, parental education, place of residence, mother'due south educational level, socio-economical status of household, preceding birth interval and birth order, religion, exposure to media, maternal malnutrition, mother's working status, paternal age, partitioning, and survey year.

The findings from this study revealed that the mother frailty model is the best model according to the likelihood ratio tests. The gender of the index kid was a pregnant factor for childhood mortality. Female children were less likely to dice within first five years of life compared to the male person children (Hour = 0.85, 95% CI = 0.75–0.98). The maternal age at birth was retained as a pregnant explanatory variable. Children from mothers with age at nascency 25-34 years had a lower risk of dying compared with those born to mothers anile less than 25 years in all models. Similar results were found amidst the fathers with age 26–35 years (Hour = 0.79, 95% CI = 0.64–0.97) compared to fathers with current age less than 26 years. The stiff but unsurprising result is the effect of maternal and paternal education. The risk of mortality was significantly lower amid children whose parents had secondary or higher pedagogy compared to the children whose parents had no education. For example, the risk was virtually 27 and 28% lower amid children with secondary or higher educated mothers and fathers, respectively, compared to not-educated parents.

Preceding birth interval and birth society were also associated with mortality. In improver, children of 5 or college nascency order with a birth interval ≤24 months were at higher take chances of bloodshed compared to the children who were the first births. But the probability of dying was declining significantly for the children with medium nativity interval and 2 or higher birth gild. The children from working women were 1.24 times at greater chance of dying than those who were not working. The likelihood of child mortality was 1.53 times higher among children from Sylhet division when compared with the Barisal sectionalisation. The other divisions didn't prove much difference in child mortality. In addition, the probability of dying was significantly reduced over the time. The likelihood of child mortality was declined by 15 (in 2011) and 24% (in 2014) times compared to the year 2007. On the other paw, we did not find whatsoever significant clan of maternal age at spousal relationship, organized religion, household socioeconomic status, mothers' exposure to media, and place of residence of the respondents with child mortality.

Nosotros also included two frailty terms that assumed to operate on a meaningful level. The mother frailty may capture any unobserved variables that operate on children built-in from the aforementioned mother, such every bit genetic factors and maternal competence. The customs level frailty may account for the possible effects of climate, ritual practices or environmental factors within the community. The maximum log likelihood of the female parent frailty model is -8151, which corresponds to the value 0.5734 of the estimated random effect variance, and a maximum log likelihood value of -8561 for the community frailty event, which corresponds to the estimated random effect variance of 0.1066.

Median hazard ratio indicates that the median increase in the hazard of bloodshed when comparing the children at a community with higher bloodshed to the children at a community with lower mortality was about 37%, which was a whopping 119% (more than than 2 times) when comparing the children of the mothers with higher and lower mortality. Kendall'due south tau reveals that 5 and 22% of the variation in event times were due to variation between communities and mothers, respectively. According to likelihood ratio test, these parameters are highly significant and point that survival risks in babyhood continue to vary due to unobserved factors in female parent and community level. This implies that in that location are other factors which are affecting under-5 bloodshed among children at mother and community level that are not explained past the observed covariates included in the model although the magnitude of most of the factors remains unchanged in the standard and frailty models. The results further suggest that unobservable factors related to the mothers were more than likely to be associated with a higher risk of children dying before reaching the fifth altogether than the community level unobservables.

Table 2 Cox's proportional hazards model and frailty model assay: take a chance factors of child mortality in Bangladesh (BDHS, 2007–2014)

Full size table

Discussion

Over the last years, at that place has been a steady decline in the rates of under-5 bloodshed in Bangladesh which indicates the country's level of improvement in the quality of life. These rates are also important in identifying the directions for the public health programs in People's republic of bangladesh [28]. The results of this study point that child's expiry depends on gender, parent'southward age at birth, parent's education, preceding birth interval, female parent's working status. Among the divisions, Sylhet showed significantly higher child mortality than the others. A significant pass up of the nether-5 bloodshed was likewise observed over the years. Loftier kid mortality in Sylhet division was observed due to many factors, including religious influence, superstitions, and lower sensation most child and maternal wellness care [29]. Moreover, this partitioning is as well lagging behind the other divisions in terms of receipt of antenatal care, child delivery assisted by medically trained providers, and vaccination coverage amongst the children [29].

Significant mortality differentials were observed by maternal age at birth of the child. The findings reveal a higher take a chance of death for children of younger mothers which also ostend previous research findings [30, 31]. Maternal age at birth can influence kid mortality through dissimilar perspectives. The college gamble of child death among younger mothers pertains because of immature reproductive systems and less stability to handle the complexities of childbirth [32]. Moreover, younger mothers are more likely to have low-birth-weight babies [33], which is associated with a higher risk of child decease [34].

Mother's teaching had a significant clan with child survival, which contributes through different mechanisms. A high risk of child death amid the illiterate mothers compared with the secondary or higher educated mothers is also consistent with other study findings [35, 36]. Educated mothers have improve socioeconomic status, practiced knowledge on family wellness and childcare, are more than witting most kid illness, preventive care and constructive use of modern wellness services [35–37]. In addition, instruction also helps to change the traditional familial relationships regarding decision making and empowers the mothers in diverse issues like childcare which in turn plays a role in reducing child mortality [38, 39]. In contrast, maternal employment status turned out to be contributing negatively on child survival. Though apparently surprising, past studies take shown that maternal employment can have an adverse event on the care of newborn, including infrequent breast feeding, and on personal care due to higher workload in performing the other traditionally ascribed roles within the family [40–42].

Our findings show that the risks of nether-5 mortality were significantly college for male children than for female person children. The fact that girls take a biological advantage against many causes of death than boys can be a possible caption of the college chance of boy deaths [43–46], which is due to a lesser vulnerability to perinatal atmospheric condition, congenital anomalies, and infectious diseases [47].

Pregnant differences past the length of preceding birth interval were observed in this written report. Findings from this written report bespeak that children with two or higher nascency order who were built-in with shorter birth intervals (≤24 months) were at a greater take a chance of dying before v years of age, which is consistent with previous studies [18, 48–50]. A shorter length of the birth interval may negatively bear upon maternal health, increase the susceptibility of infectious diseases, and cause familial resource competition among children [48, 51]. Poor nutritional status, low nascency weight, premature nativity may influence the risk of having a small birth size for children resulting in a college kid mortality [52, 53].

This study has demonstrated that hazard of child mortality varies due to unobserved factors not but at the family unit or mother level but also at the community level. The results of our frailty models propose that the effects of unmeasured family and customs level factors are likely to be of import for kid bloodshed in Bangladesh, specially the mother level frailty model was found particularly appropriate for the BDHS data. The family and customs hetergeneity summarize the effects of diverse unobserved factors such biological, parental competence, genetic, behavioral, customs, maternal depletion, resource contest betwixt siblings, cultural norms, ecology facts, quality of health facilities as well every bit care in health facilities and other unobserved factors.

Conclusion

This written report findings have important policy implications, especially in determining the programme needs for a sustainable decline in kid bloodshed rate, and in monitoring public wellness interventions. It is of import to look across private level and community level attributes. Increasing mother's education and empowerment may help reduce babyhood bloodshed. Reducing motherhood in younger ages and increasing the spacing betwixt births are also necessary to reduce child deaths. Another of import contextual factors such every bit quality and intendance of wellness facility, cultural practices, customs, environmental condition etc. could non be addressed in this report due to unavailability of data in the DHS. The authors suggest further studies considering these unobserved factors that are probable to exist associated with babe and child mortality to improve understand the association between family and customs level factors and child bloodshed in Bangladesh. Interventions and strategies should be targeted focusing on these characteristics to improve child health outcomes besides as time to come betterment of Bangladesh.

Limitations

In this study, nosotros have used cross-sectional data which limits any conclusions about the causality of the factors we take examined.

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Acknowledgments

The authors acknowledge the contributions of the BDHS, NIPORT, Measure out DHS and ICF for their efforts in data collection and providing open up admission to the dataset. We would like to thank Kishor Kumar Das for valuable give-and-take.

Funding

The authors received no specific funding for this work.

Availability of data and materials

The authors ostend that all information underlying the findings are bachelor without brake. The data sources used in the analysis can be accessed at http://dhsprogram.com/data/available-datasets.cfm.

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  1. Institute of Statistical Research and Preparation (ISRT), University of Dhaka, Dhaka, 1000, Bangladesh

    Jahidur Rahman Khan & Nabil Awan

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JRK conceptualized the written report, analyzed the data, and wrote the paper. NA contributed to the information analysis and writing. Both authors read and approved the final manuscript.

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Correspondence to Jahidur Rahman Khan.

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Khan, J.R., Awan, N. A comprehensive assay on child bloodshed and its determinants in Bangladesh using frailty models. Arch Public Health 75, 58 (2017). https://doi.org/10.1186/s13690-017-0224-vi

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  • DOI : https://doi.org/x.1186/s13690-017-0224-6

Keywords

  • Trends
  • Determinants
  • Child bloodshed
  • Random issue
  • Bangladesh

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